Provider Demographics
NPI:1609442540
Name:BOCKRATH, ALLISON
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:BOCKRATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 GRAND OAK TRL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-5011
Mailing Address - Country:US
Mailing Address - Phone:937-776-5019
Mailing Address - Fax:
Practice Address - Street 1:4353 E STATE ROUTE 73
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:45068-8812
Practice Address - Country:US
Practice Address - Phone:513-897-0248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY105861223G0001X
OH30.0264421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice